Outpatient Antibiotic Resistance Patterns of Escherichia coli Urinary Isolates Differ by Specialty Type

Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics

Adherence to Guideline-Recommended Adjunctive Heart Failure Therapies Among Outpatient Cardiology Practices (Findings from IMPROVE HF)

Closing the gap between internal medicine training and practice: Recommendations from recent graduates

Management of acute, uncomplicated cystitis in outpatients benefits from knowledge of drug resistance patterns in the population. However, antibiograms are often not available for the outpatient setting, and the role of host factors such as sex and age in assessing the likelihood of resistance are not well understood. We investigated whether antibiotic resistance patterns of outpatient urinary Escherichia coli isolates vary by age group and sex in a large database of antibiotic susceptibility test (AST) results from Washington State. We retrospectively analyzed AST data for outpatient urinary E. coli isolates in Washington State tested at a clinical reference laboratory from 2013 to 2017. In logistic regression models stratified by sex, we tested the associations of antibiotic resistance with patient age. We found females >50 years had greater odds than females younger than 19 for resistance to amoxicillin-clavulanate (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.22-1.69), ciprofloxacin (OR, 3.04; 95% CI, 2.48-3.74), ceftriaxone (OR, 2.58; 95% CI, 1.77-3.92), and gentamicin (OR, 1.62; 95% CI, 1.27-2.08) (all P < .001). Compared to males younger than 19, males >50 years had greater odds of resistance to ciprofloxacin (OR, 2.59; 95% CI, 1.18-5.69) and lower odds of resistance to amoxicillin-clavulanate (OR, 0.56; 95% CI, .34-.96) (all P < .05). These findings demonstrate that age and sex are associated with variability in antibiotic resistance patterns in the outpatient setting. Availability of outpatient antibiotic resistance data based on sex and age may be useful to inform empiric prescribing for outpatient UTIs and to support antibiotic stewardship efforts.

Influence of patient age and sex on delivery of guideline-recommended heart failure care in the outpatient cardiology practice setting: Findings from IMPROVE HF

Antimicrobial resistance and excessive antibiotic usage are a growing public health concern. Antimicrobial Stewardship Programs (ASPs) aim to optimize antibiotic use and curb resistance. This retro-respective study evaluated the impact of an ASP at Madinat Zayed Hospital, Abu Dhabi (January 2021-December 2022). It analyzed electronic health records to assess the ASP's impact on antibiotic consumption, resistance patterns, and economic outcomes. Patients from intensive care units, medical wards, and outpatient settings were included, though patients admitted to obstetrics/gynaecology, paediatrics, neonatal intensive care, and surgical wards were excluded. The primary objective of this study was to report on the ASP experience and measure the prescribing appropriateness percentage of empirical antibiotic therapy along with the de-escalation of broad-spectrum antimicrobials, after ASP implementation at Madinat Zayed Hospital in Al Dhafra Region, United Arab Emirates. The secondary objectives were to reflect on the rate of Multidrug-Resistant Organisms (MDROs), total utilization using defined daily dose, and the total direct cost of antibiotics. Descriptive analysis, proportions, mean values, and percentage changes were employed for data analysis. The ASP achieved high compliance rates with restricted antibiotics (&gt;90%) and approved guidelines (inpatient 97-100%, outpatient 93-98%). Antibiotic de-escalation rates were also high (&gt;80%). Significant reductions in use were observed for cefixime (91.3%), levofloxacin (46.3%), and several others. Notably, cefepime use increased (1137.5%). Direct antibiotic expenditure decreased by 2% (saving Dhs2.6 million), and resistance decreased in some bacteria. However, a concerning rise in ceftazidime resistance against Pseudomonas aeruginosa was identified. This study concluded that the implementation of a new Antimicrobial Stewardship Program at Madinat Zayed Hospital demonstrated effectiveness in promoting responsible antibiotic use. The program achieved high compliance with restricted antibiotic use and approved guidelines, leading to significant reductions in overall antibiotic consumption. Keywords: Antimicrobial, resistance, Multidrug-Resistant Organisms, de-escalation, consumption

BackgroundAntibiotic-resistant E. coli (EC) infections represent a major cause of morbidity and mortality, and pose a challenge to antibiotic stewardship. At present, clinicians in outpatient facilities may not have access to local antibiogram data to guide stewardship. Additionally, antibiotic resistance may vary between types of outpatient practices.MethodsUsing the database of a major clinical reference lab, this study analyzed several years of antibiotic susceptibility results for outpatient urinary EC isolates from Washington State. We compared rates of resistance to antibiotics between different types of outpatient practices, categorized using a modification of published ambulatory practice categories. Logistic regression was used to examine the association of outpatient practice type with antibiotic resistance, controlling year, sex, and age.ResultsAfter adjusting for year, sex, and age, logistic regression found significantly higher odds of resistance in urology compared with the reference groups of general family practice for ampicillin (OR 1.35), ciprofloxacin (OR 2.27), trimethoprim-sulfa (OR 1.51) and gentamicin (OR 1.73). We also saw increased odds of resistance to ciprofloxacin in patients from an oncology clinic (OR 1.56) as well as patients from “All other specialties” (OR 1.37). A lower odds of resistance was found in OBGYN clinics for ampicillin (OR 0.86), trimethoprim-sulfa (0.81) while a greater odds or resistance in OBGYN clinics was found for nitrofurantoin (OR 1.36).ConclusionAntibiotic resistance in EC urinary isolates can vary across types of outpatient practices according to clinical practice type. This may reflect differences in patient morbidity and/or differences in antibiotic stewardship practices and deserves further investigation. Patients with recurrent cases of resistant UTIs are generally referred to a urologist, and this was reflected in our data as there a higher odds of resistance was found in urology clinics. Similarly, we found higher odds of resistance into nitrofurantoin, a commonly prescribed antibiotic for UTIs in pregnant women, in OBGYN clinics that may reflect prescribing practices. Use of clinical data to create facility and specialty-specific antibiograms in outpatient settings may enable improved and “precise” antibiotic stewardship.DisclosuresAll authors: No reported disclosures.

ObjectiveTo develop, evaluate, and implement a universal online platform - termed OPEN Stewardship - to promote responsible antimicrobial prescribing (antimicrobial stewardship).IntroductionAntibiotic resistance is a mounting public health threat calling for action on global, national and local levels. Antibiotic use has been a major driver of increasing rates of antibiotic resistance. This has given rise to the practice of antibiotic stewardship, which seeks to reduce unnecessary antibiotic use across different care settings. Antibiotic stewardship has been increasingly applied in hospital settings, but adoption has been slow in many ambulatory care settings including primary care of humans. Uptake of antibiotic stewardship in veterinary care has been similarly limited. Audit and feedback systems of antibiotic use coupled with patterns of antibiotic use and best practice guidelines have proven useful in outpatient settings, but scale-up is limited by heterogeneous systems of care and limited resources.MethodsA multi-sectoral team with partners from Canada, Israel and Sweden is developing a web-based platform for administering antibiotic stewardship across multiple care settings and sectors, for human and animal prescribers. There are several interventions which support behaviour change and can be applied to antibiotic stewardship programs. Systematic reviews have found beneficial effects of numerous behaviour change interventions for optimizing clinical practice such as computerized reminders [1], opinion leaders as champions for change [2], and audit and feedback [3]. A recent Cochrane review [4] found that interventions to enable correct use of antibiotics improved policy compliance, and that enabling interventions that included feedback were more likely to be effective. We will use antibiotic prescribing benchmarking, focused guidelines, and local patterns of antibiotic resistance as key components that can be deployed as feedback through this antibiotic stewardship platform.The OPEN Stewardship platform will be hosted on an AWS cloud-based server using industry standard encryption. The platform will function with a central administrator who will enroll and deliver feedback to participating prescribers. This platform will be evaluated prospectively in two countries (Canada and Israel) to evaluate user experience of the feedback as well as impact on antimicrobial prescribing. The evaluation will include prescribers from both human and animal health. After the prospective evaluation, the platform will be made available online for broad multi-sectoral use.ResultsWe have designed the interface for a web-based platform for antibiotic stewardship which will be used in a multinational prospective primary care stewardship intervention in 2019 and 2020 and subsequently rolled out for broad public use (www.openasp.org). The platform layout can be seen in Figure 1. Data capture for aggregate prescriber level antibiotic use and local guidelines will be possible through both a manual graphical user interface and a dataset template upload. Antibiotic resistance data will be pulled from a companion database (www.resistanceopen.org). Administrators will be able to generate unique feedback forms containing visualizations and snapshots from antibiotic use, guidelines, and antibiotic resistance data (Figure 2). These can then be delivered by email on an individual or scheduled basis for one or multiple prescribers simultaneously. Participating prescribers will also have the option to login to view their own profile and browse antibiotic use, resistance and guidelines.ConclusionsAntibiotic stewardship needs to be adopted in a fashion that is country and context specific and not administered from the top down. With our approach we seek to empower groups from any country or care setting to provide regional and tailored stewardship feedback through an open interface. We have here demonstrated the design of an web-based antibiotic stewardship platform which will be evaluated prospectively and subsequently made available for open and broad multi-sectoral use - in keeping with a One Health approach.

BackgroundAntibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.MethodsMEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0–18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.ResultsOf the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.ConclusionsPediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Pharmacists critical to managing antimicrobials, developing infection control procedures

Antimicrobial resistance (AMR) is a growing global concern primarily driven by the overuse and inappropriate utilization of antimicrobials. In Nigeria, AMR is exacerbated by the routine sale of prescription-only medicines, including antimicrobials, without proper monitoring. The National Action Plan for Antimicrobial Resistance (2017-2022) highlighted widespread inappropriate antibiotic use, with significant proportions obtained without prescriptions. Antimicrobial stewardship (AMS) in outpatient settings is a novel concept in Nigeria. This interventional study sought to contribute to the reduction of inappropriate antibiotic dispensing and use in community/outpatient settings in Nigeria, focusing on enhancing the skills and capacity of improved rational antibiotic therapy among community pharmacists and Patent and Proprietary Medicine Vendors (PPMVs), with the sole aim of improving patient health outcomes. The CAMS interventional study involves education, quality improvement capacity building, patient empowerment, and a multifaceted AMS strategy. Results from the CFID’s CAMS model indicated a significant improvement in the rational dispensing and use of antimicrobials within the intervention group, emphasizing the effectiveness of CAMS. Notable variations in post-visit actions between the intervention and monitoring groups further support the positive impact of the intervention. Variation in attitudes towards sharing of antibiotic to friends and relatives was reduced among the intervention group, offering clear understanding into the potential impact of CFID AMS outpatient setting (CAMS) intervention. The study’s conclusion underscores the pivotal role of implementing AMS in outpatient and community settings such as the CAMS interventional model in improving antibiotic-related practices in both urban and rural communities in Nigeria, emphasizing its relevance and impact.

Antimicrobial stewardship interventions are targeted efforts by healthcare organizations to optimize antimicrobial use in clinical practice. The study aimed to explore effective interventions in improving antimicrobial use in hospitals. Literature was systemically searched for interventional studies through PubMed, CINAHL, and Scopus databases that were published in the period between January 2010 to April 2022. A random-effects model was used to pool and evaluate data from eligible studies that reported antimicrobial stewardship (AMS) interventions in outpatient and inpatient settings. Pooled estimates presented as proportions and standardized mean differences. Forty-eight articles were included in this review: 32 in inpatient and 16 in outpatient settings. Seventeen interventions have been identified, and eight outcomes have been targeted. AMS interventions improved clinical, microbiological, and cost outcomes in most studies. When comparing non-intervention with intervention groups using meta-analysis, there was an insignificant reduction in length of stay (MD: −0.99; 95% CI: −2.38, 0.39) and a significant reduction in antibiotics’ days of therapy (MD: −2.73; 95% CI: −3.92, −1.54). There were noticeable reductions in readmissions, mortality rates, and antibiotic prescriptions post antimicrobial stewardship multi-disciplinary team (AMS-MDT) interventions. Studies that involved a pharmacist as part of the AMS-MDT showed more significant improvement in measured outcomes than the studies that did not involve a pharmacist.

Healthcare institutions implement antimicrobial stewardship (AMS) programmes to optimize the use of antibiotics. The focus is often on inpatient rather than outpatient settings. We aimed to explore perceptions of AMS stakeholders on effective interventions for appropriate antibiotic use in outpatient settings, and the role of clinical pharmacists in the AMS multidisciplinary team. A qualitative semi-structured interview study using thematic analysis by two researchers independently. Participants that practice AMS programmes were recruited from healthcare facilities in the United Arab Emirates (UAE). Interviews were conducted face to face or online and transcribed verbatim. Four themes emerged: (i) Perceived factors leading to unnecessary or inappropriate antibiotic prescribing and their impact on patients and the community; (ii) current outpatient AMS activities and perceived barriers and facilitators for their sustainability; (iii) suggested outpatient AMS strategies to be implemented in outpatient settings; and (iv) perceived future AMS implementation barriers and suggested mitigation strategies. Several AMS interventions, together with the presence of a clinical pharmacist, may be effective in improving antibiotic use in UAE outpatient settings. Future research should investigate the most appropriate AMS strategy considering barriers and possible mitigation strategies to ensure sustainability.

Recognition of antibiotic stewardship programs (ASPs) as essential components of quality health care has dramatically increased in the past decade. The value of ASPs has been further reinforced during the coronavirus disease 2019 (COVID-19) pandemic because these programs were instrumental in monitoring antibiotic use, assessing emerging COVID-19 therapies, and coordinating implementation of monoclonal antibody infusions and vaccinations. ASPs are now required across hospital settings as a condition of participation for the Centers for Medicare and Medicaid Services and for accreditation by The Joint Commission. In the 2019 National Healthcare Safety Network annual survey, almost 89% of hospitals met the Seven Core Elements for ASPs defined by the Centers for Disease Control and Prevention. More than 61% of programs were co-led by physicians and pharmacists, evidence of the leadership role of both groups. ASPs employ many strategies to improve prescribing. Core interventions of preauthorization for targeted antibiotics, prospective audit and feedback, and development of local treatment guidelines have been supplemented with numerous emerging strategies. Diagnostic stewardship, optimizing duration of therapy, promoting appropriate conversion from intravenous to oral therapy, monitoring at transitions of care and hospital discharge, implementing stewardship initiatives in the outpatient setting, and increasing use of telemedicine are approaches being adopted across hospital settings. As a core function for medical facilities, ASP leaders must ensure that antibiotic use and ASP interventions promote optimal and equitable care. The urgency of success becomes progressively greater as complex patterns of antibiotic resistance continue to emerge, exacerbated by unpredictable factors such as a worldwide pandemic.

The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.